
==== Front
Clin Med (Lond)
Clin Med (Lond)
Clinical Medicine
1470-2118
1473-4893
Royal College of Physicians

S1470-2118(24)05421-6
10.1016/j.clinme.2024.100236
100236
Quality Improvement article
Improving the systematic screening and documentation of mental capacity for patients with severe brain injury: The Mental Capacity Screening assessment tool (MCScreen)
Turner-Stokes Lynne lynne.turner-stokes@nhs.net
ab⁎
Benaichouche-Motam Karima b
Goodison William c
Altaie Adam b
Howard Alice b
McKnight Patrick b
Alfonso Jessie b
a Department of Palliative Care, Policy and Rehabilitation, Faculty of Nursing, Midwifery and Palliative Care, King's College London, UK
b Regional Hyper-acute Rehabilitation Unit, London North-West University Hospitals Trust, UK
c Rehabilitation Medicine, National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS, UK
⁎ Corresponding author at: Regional Hyper-acute Rehabilitation Unit, Northwick Park Hospital, Watford Road, Harrow, Middlesex HA1 3UJ, UK. lynne.turner-stokes@nhs.net
20 8 2024
9 2024
20 8 2024
24 5 1002367 8 2024
7 8 2024
12 8 2024
© 2024 The Authors
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
For patients who may lack capacity, the Mental Capacity Act 2005 requires capacity to be assessed for each decision at the time that treatment is offered, but this is not practical for every element of basic care and intervention delivered to patients undergoing rehabilitation following acquired brain injury, especially if their needs are changing. In this quality improvement project, we introduced a system for screening Mental Capacity and documentation to identify patients with a) largely intact cognition for whom capacity may be reasonably be presumed, and b) those in prolonged disorders of consciousness who clearly lacked capacity for all decisions. This enabled the multidisciplinary team to concentrate on evaluation of capacity in the third group who had more nuanced ability and required detailed assessment or support for decision-making. Two rounds of audit demonstrated that implementation improved the consistency of assessment and documentation. Multicentre roll-out of this approach is now required.

Keywords

Quality improvement
Rehabilitation
Mental capacity assessment
Screening
Consciousness disorders
==== Body
pmcIntroduction

After severe acquired brain injury (ABI), many patients have cognitive or communicative deficits that affect their ability to make decisions about their basic care and treatment.1 In England, the Mental Capacity Act (MCA) 2005 requires that all such decisions for patients who lack capacity to decide for themselves should be made for them on the basis of their best interests and in line with their likely wishes, so far as these can be ascertained.2

A systematic review has estimated that 34% of patients in medical settings may lack the ability or capacity to make decisions about their treatment.3 The MCA 2005 requires that, where lack of capacity is suspected, mental capacity for decision-making should be routinely assessed and documented to establish the legal basis for all treatments given. This applies not only to medical treatments, but to any intervention, including basic nursing care and rehabilitation. While many of these interventions are essential to maintaining health, they can at times be quite intrusive (for example tracheostomy suction, oral hygiene, bladder or bowel care).

According to the MCA 2005, patients should be presumed to have capacity unless proven otherwise, but this may not be as straightforward as it seems. In the context of severe brain injury, where many patients are expected to have cognitive and/or communication deficits even if they are not immediately visible, it will sometimes be appropriate to suspend this presumption while more in-depth evaluation takes place.4 The purpose of that evaluation is not only to explore their ability to make capacitous decisions, but to consider any means of facilitation to enable them to do so.

Moreover, capacity is decision specific. Technically, capacity should be assessed for each decision at the time that treatment is offered. While this may be feasible for one-off interventions (such as surgery, procedures, courses of medication etc), it is not practical for each and every time that basic nursing care or therapy is offered in the course of an inpatient rehabilitation programme – particularly where it is clear that a patient has profound impairments (for example prolonged disorders of consciousness5 or very severe cognitive and/or communication disorders) that effectively prevent them from engaging in any decision-making process.

Qualitative studies have highlighted some of the challenges to systematic capacity assessment in routine clinical practice.6 NICE Guidelines for Decision-making and Mental Capacity (2018)7 accept (1.4.7) that ‘While the process applies to all decisions that fall within the scope of the MCA2005, both large and small, the nature of the assessment and the recording of it should be proportionate to the complexity and significance of that decision’. Previous studies have examined capacity for decision-making in the context of ABI8,9 and developed tools to document different levels of capacity impairment (none, mild/moderate, severe).9 However, to our knowledge, no tool exists to support the process of systematic screening and documentation of capacity for basic care, and treatment in routine clinical practice.

In June 2021, a spot-check of patients’ notes in our tertiary neurorehabilitation centre demonstrated documentation of mental capacity for specific procedures (eg gastrostomy placement) but failed to identify formal documentation of mental capacity for decision making for basic nursing care or rehabilitation for any patients then on the unit. Discussion within the team and with colleagues in other units revealed a popular, but mistaken, belief that these interventions were provided as part of their clinical ‘duty of care’ and must by default be in the patients’ best interests and so did not require formal capacity assessment and documentation in the same way as other ‘more serious’ interventions (such as operative procedures). Using a quality improvement (QI) approach,10 we developed a Mental Capacity Screening assessment tool (MCScreen) as a simple means for the multidisciplinary team to document on admission whether patients had any cognitive and/or communication deficits that were likely to affect decision making regarding their care and treatment. And, if so, what further evaluation may be required to determine their capacity to consent to the care and rehabilitation programme, needs for support to make decisions, etc. This article presents the process for screening and documentation of capacity and the findings from application of the MCScreen in two consecutive cohorts of patients after the tool was introduced.

Methods

Setting: The Regional Hyper-acute Rehabilitation Unit is a tertiary specialist inpatient rehabilitation for patients who have highly complex needs for care and rehabilitation, mainly following ABI.11 The majority of patients have very severe ABI with a range of cognitive and/or communicative problems. About half of the caseload comprises patients in prolonged disorders of consciousness (PDOC), who have no consistent responses or functional communication and therefore, by definition, lack the capacity to make any decisions regarding their care and treatment while they remain in that state.5

Methodology: Quality improvement (QI) is an iterative process of change and development that engages staff and service users, using data to drive improvement with the primary intent of bringing about measurable improvement to a specific aspect of healthcare delivery.10There are various different methodologies for QI. The method used here is summarised in Table 1. In brief we first used a FOCUS framework12 in which we identified the problem, assembled the team, clarified the current process, identified the shortfalls and selected the improvement. We then used a plan, do, study, act (PDSA) model in two linked cycles along the lines described by Deming 198613 to adopt the change, learn from the results and refine the process.Table 1 Overview of the QI project according to the FOCUS and PDSA frameworks.

Table 1:Framework/description	Application in this study	
FOCUS		
F	Find a process to improve	Assessment and documentation of mental capacity for basic care and rehabilitation in patients who may lack capacity	
O	Organise a team who knows the process	Our core team comprised the unit's multidisciplinary team of medical, nursing and therapy staff (including physiotherapists, occupational therapists, psychologists, SLT, dietician and social worker)	
C	Clarify current process / knowledge	In an initial preliminary retrospective audit, 20 sets of patient records showed documentation of mental capacity for certain procedures (eg gastrostomy placement) but no formal documentation of capacity to consent to receive basic medical and nursing care or the multidisciplinary rehabilitation programme (eg physiotherapy, occupational therapy, SLT, dietetics, social work etc). Discussion with colleagues in similar units suggested that this was by no means unique.	
U	Understand the reasons for shortfall in standards	After team discussion, the primary reason for lack of documentation was the time involved to document separately capacity for each intervention, which was simply not practical, especially for patients with disordered consciousness	
S	Select the improvement	We developed a simple tool (the MCScreen) to screen for capacity, document it in those who clearly do or do not have capacity for all care and treatment, and identify those requiring further assessment	
PDSA model in two cycles		
Cycle 1 – May–December 2021	
Plan	Plan a change or test aimed at improvement	The objective for cycle 1 was to pilot the MCScreen (version 1) to:
a) improve documentation of capacity for basic care and treatment
b) identify those requiring more detailed evaluation by the MD Team	
Do	Carry out the change or test	The MCScreen was to be applied by the medical team during first ward round after admission	
Study	Examine the results and learning. What went wrong?	Of 50 patients admitted, 88% were screened and four had full capacity.
(43%) were in PDOC (all had documented capacity).
But capacity was only documented in 50% of the 21 who required further assessment/ discussion	
Act	Adopt the change, abandon it or run through cycle again	The change was adopted but the process was expanded upon in cycle 2.	
	
Cycle 2 – January–December 2022	
Plan	Plan a further change / test	In addition to the MCScreen, we developed a follow-up screening tool to document the results of further assessment, and specific forms for documenting lack of capacity for patients in PDOC or with very severe cognitive and/or communicative deficits who clearly lack capacity for any decisions. A database was set up to monitor documentation	
Do	Carry out the change or test	These refinements were introduced in 2022 and audited for a further period of 12 months	
Study	Learn from the results	Analysis showed improvement but still fell short of full compliance. This was partly due to staff shortages to carry out assessments, but also lack of understanding about what was required	
Act	Further plan	We introduced a staff training programme and a schema for assessment to guide staff	
MCScreen = Mental Capacity Screening Assessment Tool; PDOC = prolonged disorders of consciousness; SLT = speech and language therapists

Our expectation was that patients should have timely initial screening and documentation of their capacity to make decisions regarding their basic care and treatment in the rehabilitation programme. For this purpose, they were divided into three groups – 1) those with presumed capacity, 2) those with uncertain capacity requiring further evaluation, and 3) those clearly lacking capacity for all decisions (see Table 2). The reasons for this separation are pragmatic – it enables the team to identify those patients requiring no further capacity assessment for basic care and treatment (unless their condition changes) in order to allow the team to concentrate their time and effort on those still requiring more detailed capacity assessment. Typically in the context of profound brain injury, there will need to be a more detailed evaluation of the patientʼs underlying cognitive and/or language abilities including insight, memory, ability for abstract thought as well as assessment of variability, because patients with severe ABI typically fatigue and fluctuate over time. They may also require assessment for ability to use assistive technology (such as communication aids, eye gaze technology etc.) to compensate for lost function.Table 2 Mental capacity screening and assessment in three groups.

Table 2:Capacity group after screening	Description	Documentation	
1.	Presumed capacity	Patients with higher-level cognitive and communicative function who may be presumed to have capacity for basic care treatment and rehabilitation.
No further capacity assessment is required (unless subsequent evidence suggests otherwise).	Screening assessment confirming presumption of capacity for all decisions regarding their care and treatment.
Follow-up assessment form confirms the legal basis for care and treatment.	
2.	Uncertain capacity	Patients for whom capacity is uncertain for at least some aspects of their care and rehabilitation requiring further evaluation
Further capacity assessment required.	Presumption of capacity is suspended pending more detailed evaluation by the multidisciplinary team (MDT) to confirm or reject the presumption of capacity.4	
3.	Clearly lacking capacity:	Those with very severe cognitive and/or communication deficits including patients who clearly lack capacity for all basic care and treatment, eg because:• they are in PDOC,

• they have no day-to-day orientation towards their situation

• they have no reliable means of communication through word or gesture.

No further capacity assessment is required (unless their condition changes).	Documented statement confirming lack of capacity is signed by a consultant.
No further evaluation is required unless they emerge into consciousness or change capacity group.	
PDOC = Prolonged disorders of consciousness

Allocation of patients into these groups is accomplished through clinical assessment and discussion by the senior medical and multidisciplinary team (MDT) and the MCScreen was developed to guide and facilitate the documentation of this process. It is acknowledged that capacity assessment for decision making is an iterative process, as both the patient's condition and the decisions to be addressed may change over time. However, the focus of this particular study is on the initial screening and capacity assessment on admission to the service.

Improvement: The MCScreen is a concise clinical screening tool (presented on one side of A4 paper) that was designed to provide preliminary identification of the types of neurological deficit that may affect (but not necessarily preclude) capacity for decision making and the areas of decision making that may be affected in order to:a) assist the classification of patients into the three groups

b) guide the MDT with respect to further, more detailed, evaluation where this is required

c) identify the practicable steps and types of assistance that may be required to support the person's involvement in decision-making.

It was developed by members of the unit's MDT in July 2021. The first draft was produced by the lead author and it subsequently underwent an iterative process of refinement through serial application and discussion amongst the MDT during the first 10 weeks of piloting.

From October 2021 onwards it has been adopted on our unit for systematic completion.

The MCScreen is completed by consensus of medical team and senior nursing staff after having conducted their initial clinical evaluation (which will include general assessment of the patient's comprehension, expression and cognition (orientation, memory, reasoning, insight etc)). It is signed off by a consultant in rehabilitation medicine during the first formal medical ward round following admission. Its content is described in Supplementary Box 1.

The project was conducted in two rounds. Round 1 represented the initial application of the tool. Staff members reported through informal feedback that the MCScreen was easy to understand and timely to complete, usually taking no more than 2–3 minutes per patient. However, although it proved possible to identify the three groups of patients, further formal documentation of capacity assessment was lacking, particularly for group 2. For round 2, we therefore developed a follow-up proforma and a standard proforma for formally documenting lack of capacity for patients in Group 3 to enable the MDT to focus on assessment and documentation of capacity for patients in Group 2. These further tools were developed by the MDT through a similar iterative process of refinement through serial application and discussion. The schema for assessment is illustrated in Fig. 1. (Further information and the tools themselves may be found on our website https://www.ukroc.org/other/mc-screen).Fig. 1 Schema for screening, assessment and documentation of mental capacity for decision-making regarding basic care, treatment and rehabilitation.

Fig. 1

Data gathering: The study group comprised consecutive admissions to the unit between May 2021 and December 2022. In cycle 1 (May 2021–December 2021), patients’ records were examined for the presence of an MCScreen form. If present, the content was transcribed into a dedicated database prepared in Microsoft Excel. Thereafter, for cycle 2 (January–December 2022) the database was expanded to include the further tools and assessments which were prospectively recorded on the database. Data were extracted in January 2023 and transferred to the Statistical Package for Social Sciences (SPSS) v 28 for descriptive analysis.

This manuscript was prepared with reference to the SQUIRE guidelines http://www.squire-statement.org/index.cfm?fuseaction=page.viewPage&pageID=471.

Results

Table 3 sets out the results of audit in the two cycles. In cycle 1, 44/50 (88%) admissions had a documented MCScreen assessment (although seven forms were very incomplete). Follow-up documentation after further evaluation of capacity was not documented in approximately half of the patients. In cycle 2, 86/94 (91%) had a MCScreen documented and all were complete/near-complete (ie only one or two items missing). The median time from admission to assessment reduced from 6 days in cycle 1 to 2 days in cycle 2. The confirmation of lack of capacity for patients in PDOC was already strong in the first cycle, but the addition of tools to support follow-up assessment and to confirm the lack of capacity in patients with severe cognitive/communication deficits in cycle 2 led to substantial improvements in the ongoing documentation of team discussion and further assessment.Table 3 Cycle by cycle results of screening for capacity to make decisions about care and treatment.

Table 3:	Cycle 1 (May–December 2021)	Cycle 2 (January–December 2022)	
	Screening	Further assessment	Screening	Further assessment	
Screened with MCScreen:	44/50	88% of admissions had a screening assessment
(Seven of the 44 MCScreen forms were very incomplete)	86/94	91% of admissions had a screening assessment
(All MCScreen forms were complete or near-complete)	
Time from admission to MCScreen assessment	Mean Median	11.7 days
6 days	Mean 3.5
Median 2	3.5 days
2 days	
	
Capacity Group					
	
PDOC –
No capacity for any decision	19 (43%)	Mean time to assess 8 days (median 6 days)
All 19 had confirmation of PDOC & lack of capacity
One subsequently emerged, but it was not documented whether they regained capacity	45 (52%)	Mean time to assess 3.9 days (median 2 days); 42 (93%) had confirmation of PDOC and lack of capacity; seven emerged – of whom six had follow-up assessment• Four lacked capacity

• One regained capacity

• One had uncertain capacity requiring assessment

	
	
Team discussion	16 (36%)	Eight (50%) – no documentation of decisionFurther assessment required N = 8• Completed and documented in four (50%)

Outcome:• One had capacity

• Three lacked capacity

• Four no documented outcome of assessment

	28 (31%)	27 (96%) – documentation of decision• Six – Presumed capacity – confirmed in five

• Three lacked capacity

Further assessment required N = 19• Completed and documented in 18 (95%)

Outcome:• Eight had capacity (four for some decisions only)

• Nine lacked capacity

• One required further follow-up

	
	
Further assessment	5 (11%)	Three (60%) – no documentation of decisionFurther assessment completed and documented• Completed in 2/5 (40 %)

Outcome:• One lacked capacity (20%)

• One undocumented

	3 (3.5%)	0 – no documentation of decisionFurther assessment completed and documented• Completed in all three (100%)

Outcome:• Two had capacity (decision-specific in both)

• One lacked capacity

	
Presumed capacity	4 (9%)	Documented - Has capacity – no follow-up needed	10 (12%)	Documented - Has capacity – no follow-up needed	
MCScreen = Mental Capacity Screening Assessment Tool; PDOC = prolonged disorders of consciousness

Across the two cycles, a total of 123/130 patients had complete/near-complete MCScreen documentation for inclusion in further analysis. Their mean age was 48.8 years (SD 14.1, range 17–72). The male: female ratio 63:37%. A total of 125 (95%) had acquired brain injury (due to cerebrovascular accident 71 (54%)), trauma 22 (17%), hypoxia 21 (16%), other 11(8%)). Three had Guillain–Barre syndrome and three had other diagnoses.

The results of MCScreen assessment are shown in Tables 4 and 5. In Table 4, patients are divided into those admitted for evaluation of PDOC (N = 64) and those who were conscious and admitted for rehabilitation (n = 59).Table 4 Analysis of screening results (n = 123 with complete/near complete forms).

Table 4:	Rehabilitation programme
N = 59	PDOC programme
N = 64	
Compliance with MCScreen completion	
 Screening form in notes
Fully complete
Signed by consultant	59 (100%)
50 (85%)
56 (95%)	64 (100%)
59 (92%)
60 (94%)	
Impairment of brain	
 Yes
No	56 (95%)
3 (5%)	64 (100%)
-	
Overall capacity group	
 Largely intact – presume capacity
Uncertain requires further evaluation
PDOC – lacks capacity	17 (29%)
42 (71%)
-	-
-
64 (100%)	
Barriers that may impact on capacitya	
 Cognitive	37 (63%)		
 Communicative	36 (61%)		
 Sensory	5 (9%)		
 Communication barriers due to English not being their first language	4 (7%)		
Capacity domains likely to be affecteda	
 Understanding information	28 (48%)	–	
 Retaining information	23 (39%)	–	
 Weighing it up	25 (42%)	–	
 Communicating the decision	28 (48%)	–	
 All aspects of decision-making	25 (48%)	63 (98%)	
Further evaluation requireda (where positively identified)	
None – unless capacity group changes	7 (12%)	60 (94%)	
Team discussion	41 (70%)	3 (5%)	
Further detailed assessment	51 (86%)	1 (2%)	
Who by (where specified):			
 Psychology	15 (25%)	1 (2%)	
 Speech and language therapy	18 (31%)	1 (2%)	
 Medical	2 (3%)	1 (2%)	
 Other	1 (2%)		
Interpreter required	2 (3%)	–	
Facilitation required	6 (10%)	–	
PDOC – Prolonged disorder of consciousness

a More than one may apply

Table 5 Aspects of care for which patient had capacity.

Table 5:	Yes, presume capacity	No	Uncertain at present	Missingd
ataa	
Non-PDOC patients	
Nursing and care	28 (48%)	4 (7%)	26 (44%)	1	
Therapy intervention	23 (39%)	4 (7%)	31 (53%)	1	
Treatment escalation planning	17 (29%)	10 (17%)	21 (53%)	1	
PEG/tube feeding	15 (25%)	8 (14%)	23 (39%)	1	
Medical interventions	21 (36%)	9 (15%)	28 (48%)	1	
Place of care on discharge	14 (24%)	7 (12%)	35 (59%)	2	
	
PDOC patients	
	
Nursing and care	–	62 (97%)	–	2	
Therapy intervention	–	62 (97%)	–	2	
Treatment escalation planning	–	62 (97%)	–	2	
PEG/tube feeding	–	62 (97%)	–	2	
Medical interventions	–	62 (97%)	–	2	
Place of care on discharge	–	62 (97%)	–	2	
PDOC – Prolonged disorders of consciousness

a Not completed at screening pending further team discussion

In the PDOC group, after initial assessment with the MCScreen, 60/64 had a formal statement of capacity (signed by a consultant) declaring that they lacked capacity for all decisions regarding their care and treatment. Of these, 51 (85%) were in a low level of consciousness (on the border of vegetative and minimally conscious state (MCS-minus)), while seven (12%) showed higher-level behaviours, but were still in a minimally conscious state (ie ‘MCS-plus’ according to the definitions in Chapter 1 of the national clinical guidelines5). Nine patients emerged into consciousness during their stay, of whom six had further formal assessment of their capacity, but all continued to lack capacity for any decisions due to their very severe ongoing cognitive/communication disorder.

In the rehabilitation group, 29% were largely cognitively intact and presumed to have capacity, while in 71% capacity was uncertain and required further evaluation. The main problems that were identified as likely to affect their capacity were cognitive deficits (63%) and/or communication difficulties (61%). The four domains of capacity (ie understanding, retaining, weighing up information and communication) were broadly equally affected. Fifty-one (86%) required further detailed evaluation of capacity for decisions regarding their basic care and treatment. These included 10/17 patients initially screened as having ‘largely intact cognition’, of which six (60%) were subsequently found on further detailed assessment to have capacity for some decisions, but not for others.

Discussion

Assessment of mental capacity in patients with complex brain injury can be complex and time-consuming in clinical practice. Although the relevant NICE Guidelines7 acknowledge that assessment and documentation should be proportionate to the complexity and significance of decision, they do not provide guidance on how this proportionality could be achieved. As demonstrated in the initial FOCUS phase of this project, clinicians often take for it for granted that the provision of basic nursing care and therapy must be in the patients’ best interests, without pausing to consider the legal basis on which they provide those (sometimes intrusive) interventions. Our preliminary exploration demonstrated almost no formal documentation of capacity to consent to receive these routine interventions, but discussion with colleagues in other rehabilitation units has suggested that this experience is by no means unique.

In this Quality Improvement project, we used the ‘FOCUS’ framework and the ‘plan, do, study, act’ model to develop and refine a scheme to screen for and document mental capacity to make decisions about different aspects of basic care and treatment that are routinely offered in the context of an inpatient rehabilitation unit, and thus to define the legal basis on which they are delivered. The MCScreen tool proved to be simple and timely to use. The system was refined over the course of two audit cycles with additional tools developed to facilitate follow-up and document further assessment. The results of the second-round audit demonstrate improved consistency of application with more timely and complete MCScreen forms, as well better recording of follow-up assessments and documentation of capacity for those who required more detailed evaluation.

Some patients with frontal lobe brain injury have dysexecutive problems that affect their insight and ability to problem-solve or make decisions in everyday life, and yet perform well in interview or test settings. Our finding that a significant proportion of patients initially thought to have ‘largely intact cognition’ turned out not to have capacity for some decisions regarding their basic care and treatment, is a further reminder of the need for clinicians to be aware of this ‘frontal lobe paradox’ in the context of capacity assessment.14 This in turn supports the value of suspending the presumption of capacity4 pending more in-depth evaluation of capacity in some patients (especially for higher-risk decisions), even though it may, a first sight, go against the principles of the MCA 2005.

Other programmes have identified some of the challenges associated with assessment of mental capacity in the context of complex cognitive and/or communication deficit,6 and have provided detailed toolkits to enable hospital staff to carry out high quality mental capacity assessments and identify and support the needs of patients with communication difficulties – for example the Mental Capacity Assessment Support Toolkit (MCAST).15 These tools are very useful, particularly for assessment in patients who may have capacity for some decisions given appropriate support, or they are able express their general wishes, but are not necessarily able to assimilate and weigh up complex/abstract information to make fully informed decisions about their future care and treatment. However, there is little literature that addresses the very real practical difficulties that hard-pressed clinical teams experience with the assessment and documentation of capacity for the full range of decisions that need to be made at the coalface of acute medical care, especially in clinical situations that can change quite rapidly. To our knowledge this is the first published schema to take a pragmatic approach – identifying and distinguishing those patients who clearly have capacity, or who lack have capacity for any decision, and so freeing up time for professions to spend on assessing patients with more nuanced capacity and their requirements for supported decision-making.

Lessons learned: Even with the simplified approach used here, the assessment of capacity is complex and time-consuming, especially in a post-acute rehabilitation setting where the patient's condition (and therefore capacity for decision making) may change over time. This means that assessment is an iterative process. Through their active involvement in repeated audit cycles, this QI project has helped to raise awareness of the team's collective responsibility in this regard, not only in capacity assessment but also in the process of monitoring and documentation. The standardised documentation has helped very considerably to direct and monitor this process, but it continues to need close supervision and strong consultant leadership.

The authors acknowledge some limitations to this study.1. It is conducted in a single centre, so the generalisability of the findings has yet to be demonstrated.

2. The population is unusual for most healthcare settings due to the high proportion of patients in PDOC, although it is not entirely atypical of other Level 1 tertiary rehabilitation units in the UK.

3. The MCScreen has not been subjected to tests of inter- and intra-rater reliability, although these would be difficult as it is designed to be rated by consensus of treating multidisciplinary team and is known to change over time (if the patient's condition changes or if more information becomes available). It therefore should not be viewed as an instrument to determine capacity per se, but as a tool to highlight the need for further assessment and to guide the process of capacity evaluation, including any changes over time.

The above limitations acknowledged, this QI development represents an important first step towards the consistent evaluation of capacity for basic care and treatment. Improved documentation and structured assessments foster a more consistent approach to capacity assessment, helping to ensure that staff fulfil the statutory requirements of the MCA 2005, and importantly that patients' legal rights under the Act can be met more effectively. Although developed in the context of rehabilitation following ABI, this approach has potential for wider application in other settings, such as care of the elderly, stroke units etc. However, the immediate next steps are to roll the process out and evaluate the applicability of the model in other rehabilitation units that serve a similar group of patients.

Funding statement

Funding from London North-West Healthcare University NHS Trust Charitable funds also contributed to support this study.

Ethics approval

As this was a quality improvement project, research ethics permission was not required.

Data sharing

For reasons of confidentiality and data protection, data sharing is not available at the current time. Copies of the tools used in this study are available free of charge from the authors. Please visit our website for more details and contact information: https://www.ukroc.org/.

CRediT authorship contribution statement

Lynne Turner-Stokes: Conceptualization, Methodology, Formal analysis, Data curation, Writing – original draft, Project administration. Karima Benaichouche-Motam: Investigation, Writing – review & editing. William Goodison: Software, Investigation, Writing – review & editing. Adam Altaie: Writing – review & editing. Alice Howard: Conceptualization, Investigation, Writing – review & editing. Patrick McKnight: Conceptualization, Investigation, Writing – review & editing. Jessie Alfonso: Writing – review & editing.

Declaration of competing interest

There are no personal or financial conflicts of interest.

All authors are employed by Northwick Park Hospital, King's College London, or University College London Hospitals NHS Foundation Trust, which may cite this article as part of their quality improvement and development programmes.

We do not consider that any of these relationships or activities have influenced the submitted work.

Appendix Supplementary materials

Image, application 1

Acknowledgements

The authors are grateful to the patients and members of the Regional Hyper-acute Rehabilitation Unit team who have contributed to this programme, and to successive iterations of the MCScreen and associated tools. Particular thanks are to Dr Aung Nay and Ms Dimple Baria for their assistance in gathering and entering the data.

Supplementary material associated with this article can be found, in the online version, at doi:10.1016/j.clinme.2024.100236.
==== Refs
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